Every finding on record at Vnacare

Upon patient record review 2 of 19 (Patient #7, 9) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient #7: There was no evidence of a spiritual care assessment of the patient or family. Chaplain services were declined. There is no evidence that the RN or the SW completed this part of the assessment. Patient #9: There was no evidence of a spiritual care assessment of the patient or family. Chaplain services were declined. There is no evidence that the RN or the SW completed this part of the assessment.

Upon patient record review, 4 of 19 (Patient #5,8,9,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 5: Current Medication Record includes Acetaminophen 500mg/15ml every 6 hours prn, Norco5mg/325mg every 6 hours prn, Acetaminophen 325 (2 tabs) every 4 hours prn. Orders do not include the maximum daily dose. Patient 8: Current Medication Record includes Acetaminophen 325mg (2 tabs) every 6 hours prn, Acetaminophen 650mg suppository every 4 hours prn. Orders do not include the maximum daily dose. Patient 9: Current Medication Record includes Triamcinolone Acetonide 0.1% cream 1gram topically to affected area. Order does not include site of application or amount to be applied. Hydrocortisone 2.5% cream 1 gram, apply thin layer to affected area. Order does not include a site of application. Nystatin 100,000 unit/gram cream to affected area. Order does not include site of application or amount to be applied. Mupirocin 2% ointment to affected area. Order does not include site of application or amount to be applied. Patient 10: Current Medication Record includes Norco 5/325 every 6 hours prn, Acetaminophen 500mg every 6 hours prn, Acetaminophen 650mg suppository every 4 hours. Orders do not include the maximum daily dose.

Upon patient record review, 4 of 19 (Patient #5,8,9,10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 5:Current Plan of Care includes Acetaminophen 500mg/15ml every 6 hours prn, Norco5mg/325mg every 6 hours prn, Acetaminophen 325 (2 tabs) every 4 hours prn. Orders do not include the maximum daily dose. Patient 8:Current Plan of Care includes Acetaminophen 325mg (2 tabs) every 6 hours prn, Acetaminophen 650mg suppository every 4 hours prn. Orders do not include the maximum daily dose. Patient 9: Current Plan of Care includes Triamcinolone Acetonide 0.1% cream 1 gram topically to affected area. Order does not include site of application or amount to be applied. Hydrocortisone 2.5% cream 1 gram, apply thin layer to affected area. Order does not include a site of application. Nystatin 100,000 unit/gram cream to affected area. Order does not include site of application or amount to be applied. Mupirocin 2% ointment to affected area. Order does not include site of application or amount to be applied. Patient 10: Current Plan of Care includes Norco 5/325 every 6 hours prn, Acetaminophen 500mg every 6 hours prn, Acetaminophen 650mg suppository every 4 hours. Orders do not include the maximum daily dose.

Upon personnel record review, 1 of 19 (Personnel #4) did not have evidence that a skills competency assessment, specific to each discipline had been conducted for all personnel including volunteers initially during orientation. Personnel #4: Bag Technique Competency (2025), tasks to be assessed were not initialed or dated.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #10: Skilled nurse assessment noted patient taking as nutrition: 3 ensure plus 500 ml of H20 daily. This is not reflected at all on the medication profile and is not reflected on the plan of care.

Upon patient record review, 1 of 19 (Patient #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #10: Skilled nurse assessment noted patient taking as nutrition: 3 ensure plus 500 ml of H20 daily. This is not reflected at all on the medication profile and is not reflected on the plan of care.

Based on interviews and record reviews, the agency failed to obtain written certification of terminal illness (anticipated six months or less life expectancy if the disease runs its normal course) from both the hospice medical director and the patient's attending physician for two of three sampled patients (Patient 1 and 2) when: 1.The certification of terminal illness for Patient 1 for the first 90-day benefit period (hospice services are provided in two 90-day periods and then an unlimited number of 60-day periods) did not include certification by Patient 1's attending physician. 2. The certification of terminal illness for Patient 2 for the first 90-day benefit period did not include certification by Patient 2's attending physician. This failure had the potential to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care too soon due to not being properly evaluated as terminally ill for Patients 1 and 2. Findings: 1. A review of Patient 1's face sheet (a document that contains resident demographics and diagnoses) indicated a start of service date of June 14, 2022, with primary hospice diagnosis of malignant neoplasm of unspecified ovary. During a concurrent interview and record review with the Hospice Supervisor (HS), on July 20, 2022, at 10:25 AM, of Patient 1's medical record titled, "Hospice Certification of Terminal Illness," dated June 14, 2022, indicated a terminal diagnosis of malignant neoplasm of unspecified ovary. Section 6 of the same document, titled, "Benefit Period/Date Range," indicated Patient 1 was on Benefit Period 1 from June 14, 2022, to September 11, 2022. Section 15 of the same document, titled, "Attending Physician's Signature and Date." indicated it was signed by Physician 1 who was the agency's hospice physician and not the attending physician for Patient 1. During a concurrent interview and record review with the Administrator, on July 20, 2022, at 12:19 PM, the Administrator stated the Patient 1 came from the services of a home health agency before admission to their hospice care, and further stated Patient 1 has an attending physician under home health services. In a review of the agency's policy and procedure (P&P), titled, "Hospice Admission Criteria," revised September 2019, indicated, " ...Procedure ...4. The Hospice Medical Director and attending physician will jointly certify that the individual is terminally ill with a life expectancy of six months or less if the disease runs its normal course." The Administrator stated that Physician 1, whose signature appears as the attending physician certifying terminal illness for Patient 1 was not the attending physician prior to admission to hospice. The Administrator was unable to provide documentation that it tried to communicate with Patient 1's attending physician from home health. 2. A review of Patient 2's face sheet (a document that contains resident demographics and diagnoses) indicated a start of service date of June 8, 2022, with primary hospice diagnosis of breast cancer with metastatic disease to bone. During a concurrent interview and record review with the Hospice Supervisor (HS), on July 20, 2022, at 10:25 AM, of Patient 2's medical record titled, "Hospice Certification of Terminal Illness," dated June 8, 2022, indicated a terminal diagnosis of malignant neoplasm of unspecified site of unspecified female breast. Section 6 of the same document, titled, "Benefit Period/Date Range," indicated Patient 2 was on Benefit Period 1 from June 8, 2022, to September 5, 2022. Section 15 of the same document, titled, "Attending Physician's Signature and Date," indicated it was signed by Physician 2 who was the agency's hospice physician and not the attending physician for Patient 2. During a concurrent interview and record review with the Administrator, on July 20, 2022, at 12:19 PM, the Administrator stated the Patient 2 came from another hospice agency before admission to their hospice care, and further stated Patient 2 has an attending physician under previous hospice services. In a review of the agency's policy and procedure (P&P), titled, "Hospice Admission Criteria," revised September 2019, indicated, " ...Procedure ...4. The Hospice Medical Director and attending physician will jointly certify that the individual is terminally ill with a life expectancy of six months or less if the disease runs its normal course." The Administrator stated that Physician 2, whose signature appears as the attending physician certifying terminal illness for Patient 2 was not the attending physician prior to admission to their agency. The Administrator was unable to provide documentation that it tried to communicate with Patient 2's attending physician from the previous hospice agency..